CAPÍTULO 3: PROPUESTA Y VALIDACIÓN DE LA SOLUCIÓN
3.2 Validación del cuestionario
€510 shortfall per day Full cover for certain cardiac procedures in all
three hi-tech hospitals
No cover with the exception of certain cardiac procedures in Mater Private and the
Blackrock Clinic
Full cover with €300 in-patient excess in the Beacon
Hospital only. Cover for certain cardiac procedures
in Mater Private and the Blackrock Clinic
Covered with a €200 in-patient excess Full cover for certain cardiac procedures in all
three hi-tech hospitals
Covered with a €125 in-patient excess. Full cover for certain cardiac procedures in all
three hi-tech hospitals
Full cover including certain cardiac procedures in all
three hi-tech hospitals
Semi-private room in a private tier 3
hospital ––
€510 shortfall per day Full cover for certain cardiac procedures is all
three hi-tech hospitals
No cover with the exception of certain cardiac procedures in Mater Private and the
Blackrock Clinic
Full cover with €300 in-patient excess in the Beacon
Hospital only. Cover for certain cardiac procedures
in Mater Private and the Blackrock Clinic
€255 shortfall per night with €200 in-patient excess Full cover for certain cardiac
procedures in all three hi-tech hospitals
Full cover with €125 in-patient excess in the Beacon Hospital. €500 shortfall per night with €125 in-patient excess in the Mater Private Hospital and Blackrock Clinic.
Full cover including certain cardiac procedures in all
three hi-tech hospitals
Private room in a private tier 3
hospital ––
€510 shortfall per day Full cover for certain cardiac procedures is all
three hi-tech hospitals
No cover with the exception of certain cardiac procedures in Mater Private and the
Blackrock Clinic
€250 shortfall per night with
€300 in-patient excess in the Beacon Hospital only.
Cover for certain cardiac procedures in Mater Private
and the Blackrock Clinic
€255 shortfall per night with €200 in-patient excess Full cover for certain cardiac
procedures in all three hi-tech hospitals
€127 shortfall per night with €125 in-patient excess in the Beacon Hospital.
€500 shortfall per night with €125 in-patient excess in the Mater Private Hospital
and the Blackrock Clinic
Full cover including certain cardiac procedures in all
three hi-tech hospitals Excess applies here to Essential Plus with an in-patient excess, Health Smart, Essential Connect Family and
Essential Complete schemes
†Excess of €300 applies once per policy per membership year
Cover for private Northern Ireland hospitals
The North West Independant Hospital, Derry & The Ulster Independant Clinic, Belfast
Level of Cover Essential Assist Essential Essential Connect
Health Essential Connect Family† Essential Complete Health Smart Essential Plus (Excess
and No Excess) Essential Gold Out-patient surgical or daycase in
the above named Northern Ireland hospitals
Covered up to 66% of
hospital charges €255 shortfall per day Covered with €150
in-patient excess Covered with a €300
in-patient excess Covered with €125
in-patient excess Covered with €125
in-patient excess** Covered with €125
in-patient excess** Full cover Semi-private room in the above
named Northern Ireland hospitals Covered up to 66% of
hospital charges €255 shortfall per night Covered with €150
in-patient excess Covered with a €300
in-patient excess Covered with €125
in-patient excess Covered with €125
in-patient excess Covered with €125
in-patient excess Full cover Private room in the above named
Northern Ireland hospitals Covered up to 66% of
hospital charges €255 shortfall per night €250 shortfall per night plus €150 in-patient excess
€250 shortfall per night plus a €300 in-patient
excess
€150 shortfall per night plus €125 in-patient
excess
€127 shortfall per night with €125 in-patient excess
Covered with €125
in-patient excess Full cover Excess applies to Essential Connect Health, Essential Connect Family, Essential Complete, Essential Plus with
in-patient excess, and Health Smart
†Excess of €300 applies once per policy per membership year
Hospital cover for Tier (level) 3 private hospitals (hi-tech)
Blackrock Clinic, Mater Private Hospital and the Beacon Hospital
Level of Cover Essential
Assist Essential Essential Connect
Health Essential Connect Family† Essential Complete / Essential Plus /
(Excess and No Excess) Health Smart Essential Gold
Out-patient surgical or daycase in a private tier 3 hospital
––
€510 shortfall per day Full cover for certain cardiac procedures in all
three hi-tech hospitals
No cover with the exception of certain cardiac procedures in Mater Private and the
Blackrock Clinic
Full cover with €300 in-patient excess in the Beacon
Hospital only. Cover for certain cardiac procedures
in Mater Private and the Blackrock Clinic
Covered with a €200 in-patient excess Full cover for certain cardiac procedures in all
three hi-tech hospitals
Covered with a €125 in-patient excess. Full cover for certain cardiac procedures in all
three hi-tech hospitals
Full cover including certain cardiac procedures in all
three hi-tech hospitals
Semi-private room in a private tier 3
hospital ––
€510 shortfall per day Full cover for certain cardiac procedures is all
three hi-tech hospitals
No cover with the exception of certain cardiac procedures in Mater Private and the
Blackrock Clinic
Full cover with €300 in-patient excess in the Beacon
Hospital only. Cover for certain cardiac procedures
in Mater Private and the Blackrock Clinic
€255 shortfall per night with €200 in-patient excess Full cover for certain cardiac
procedures in all three hi-tech hospitals
Full cover with €125 in-patient excess in the Beacon Hospital. €500 shortfall per night with €125 in-patient excess in the Mater Private Hospital and Blackrock Clinic.
Full cover including certain cardiac procedures in all
three hi-tech hospitals
Private room in a private tier 3
hospital ––
€510 shortfall per day Full cover for certain cardiac procedures is all
three hi-tech hospitals
No cover with the exception of certain cardiac procedures in Mater Private and the
Blackrock Clinic
€250 shortfall per night with
€300 in-patient excess in the Beacon Hospital only.
Cover for certain cardiac procedures in Mater Private
and the Blackrock Clinic
€255 shortfall per night with €200 in-patient excess Full cover for certain cardiac
procedures in all three hi-tech hospitals
€127 shortfall per night with €125 in-patient excess in the Beacon Hospital.
€500 shortfall per night with €125 in-patient excess in the Mater Private Hospital
and the Blackrock Clinic
Full cover including certain cardiac procedures in all
three hi-tech hospitals Excess applies here to Essential Plus with an in-patient excess, Health Smart, Essential Connect Family and
Essential Complete schemes
†Excess of €300 applies once per policy per membership year
Cover for private Northern Ireland hospitals
The North West Independant Hospital, Derry & The Ulster Independant Clinic, Belfast
Level of Cover Essential Assist Essential Essential Connect
Health Essential Connect Family† Essential Complete Health Smart Essential Plus (Excess
and No Excess) Essential Gold Out-patient surgical or daycase in
the above named Northern Ireland hospitals
Covered up to 66% of
hospital charges €255 shortfall per day Covered with €150
in-patient excess Covered with a €300
in-patient excess Covered with €125
in-patient excess Covered with €125
in-patient excess** Covered with €125
in-patient excess** Full cover Semi-private room in the above
named Northern Ireland hospitals Covered up to 66% of
hospital charges €255 shortfall per night Covered with €150
in-patient excess Covered with a €300
in-patient excess Covered with €125
in-patient excess Covered with €125
in-patient excess Covered with €125
in-patient excess Full cover Private room in the above named
Northern Ireland hospitals Covered up to 66% of
hospital charges €255 shortfall per night €250 shortfall per night plus €150 in-patient excess
€250 shortfall per night plus a €300 in-patient
excess
€150 shortfall per night plus €125 in-patient
excess
€127 shortfall per night with €125 in-patient excess
Covered with €125
in-patient excess Full cover Excess applies to Essential Connect Health, Essential Connect Family, Essential Complete, Essential Plus with
in-patient excess, and Health Smart
†Excess of €300 applies once per policy per membership year
Note 1 - Continued
(i) Regarding the amounts listed on the above tables that we will deduct for each day of treatment that you receive in a laya healthcare participating public hospital that is not shown to be fully covered under the member’s chosen scheme, we reserve the right to change these amounts by up to 20% on an annual basis.
(ii) Minimum benefit regulations
Despite anything to the contrary in the rules and Table of Benefits of the scheme, you may claim any benefits we are required to pay under the minimum benefit regulations.
(iii) Mater Private Hospital, Blackrock Clinic, Galway Clinic and the Beacon Hospital
We will provide a full refund for hospital charges for treatment received in the Mater Private Hospital, the Blackrock Clinic, Dublin, and the Beacon Hospital, Dublin for certain types of specialist cardiac surgery under the Essential, Essential Complete, Essential Plus, Health Smart and Essential Gold schemes.
A list of the specialist cardiac surgery for which we will pay benefits in full at these hospitals is available on request. Please note: For Essential Connect Health and Essential Connect Family members we will provide certain cardiac cover in the Mater Private Hospital and the Blackrock Clinic.
(There is no cover for this benefit on the Essential Assist scheme).
(iv) Cahercalla Hospital, Ennis; Park West Clinic, Dublin 12 and the Cork Clinic We will only pay benefits for day-case and surgical out-patient treatment at these hospitals.
This applies to the Essential, Essential Connect Health, Essential Connect Family, Essential Complete, Essential Plus, Health Smart and Essential Gold schemes. We will not pay for other types of treatment at these hospitals. Essential Assist scheme members are covered up to 66%
for hospital charges for day-case and surgical
out-patient treatment at these hospitals.
* Please contact us prior to admission to the Cork Clinic to ensure your treatment is covered.
(v) St. Francis, Mullingar, St. Joseph’s, Garden Hill
We will only pay for surgical admissions at these hospitals. We will not pay for other types of treatment at these hospitals.
(vi) White Oaks Treatment Centre, Derryvane, Muff, Donegal
We will only pay benefits for up to 28 days of in-patient treatment for alcoholism, drugs or substance abuse at this centre each year. This is subject to the maximum limit of 91 days in any continuous period of five years.
(vii) Stanhope Centre, Grangegorman;
Mid-Western Radiation Oncology Centre, Limerick
We will only pay benefits for out-patient treatment at these hospitals. We will not pay for other types of treatment at these hospitals.
(viii) National MS Centre, Rathgar We will only pay benefits for up to a maximum of 14 days in-patient treatment, in any one calendar year.
(ix) Dean Clinics
Dean Clinics are Community based Mental Health Clinics owned and operated by St. Patrick’s University Hospital. Please see Benefit 4 for the amount eligible for benefit on your policy.
This is a combined benefit regardless of who the member is treated by. The Dean Clinics are located in Lucan, Donaghmede, Sandyford, St.
Patrick’s & Capel St., Cork and Galway.
(x) Lois Bridges
Lois Bridges Eating Disorder Treatment Centre offers in-patient residential treatment. In-patient treatment is eligible for up to a maximum of 40 days in a calendar year. Pre-authorisation is required for in-patient treatment.This is subject to
the maximum limit of 91 days in any continuous period of five years.
(xi) Specified Orthopaedic Procedures For members of the Essential Plus, Essential Connect Family, Essential Complete, Essential Connect Health, Essential Gold and Health Smart schemes;
These procedures and the hospitals in which a shortfall will apply may change from time to time so please contact us in advance or refer to the
“For Members – Checking Your Cover” section of our website for specific shortfalls. We will send you a copy of the most up to date Specified Orthopaedic list if you ask us to.
Note 2
If you receive treatment from a consultant who is not participating in the full cover scheme, we will pay the consultants’ fees for these services in accordance with and up to the amount shown as the standard rate in the schedule of benefits for the treatment you receive.
Note 3
(a) Hospital and consultants’ charges for radiology and pathology
Laya healthcare will only pay fees and charges for radiology and pathology if and to the extent that the radiology or pathology consists of one or more radiological procedures or pathological investigations listed in the minimum benefit regulations.
(b) laya healthcare approved laboratories, screening centres, diagnostic centres and suppliers The list of laya healthcare approved laboratory, screening, diagnostic centres and suppliers is available on request. The list of these hospitals and centres that have been approved for MRI is also available on request.
(c) Fees charged for radiology by consultants not participating in the full cover scheme
If you receive such treatment from a consultant who is not participating in the full cover scheme, we will pay the consultant’s fees for these services in accordance with and up to the amount shown as the standard rate in the schedule of benefits for this type of treatment.
(d) Home nursing
We will only pay benefits for home nursing if the home nursing followed in-patient treatment for which benefits were also payable.
Laya healthcare will only pay benefits for receiving home nursing if the sole purpose of home nursing is to enable you to reduce the period of in-patient treatment.
(e) Emergency dental injury treatment Laya healthcare will only pay benefits for restorative dental treatment immediately following an accident.
(f) Speech and language therapy, chiropody and occupational therapy The maximum number of consultations we will pay for is the overall number of consultations for any and all such treatment each year and not for each type of treatment separately.